Improving Outcomes in Laparoscopic Anterior Rectal Resection: The Benefits of REAL Score in Preoperative Risk Assessment for Anastomotic Leak

Abstract

AbstractPURPOSE To evaluate the effectiveness of a preoperative risk assessment tool called REctal Anastomotic Leak (REAL) score for predicting the risk of anastomotic leakage in patients undergoing laparoscopic anterior rectal resection with total mesorectal excision for rectal cancer. METHODS This prospective study was conducted from May 1st ,2018, to May 1st, 2021 and included a consecutive unselected series of patients undergoing elective laparoscopic anterior rectal resection with total mesorectal excision for rectal cancer. We collected data on patients' medical histories, surgical procedures, length of hospital stay, and short-term outcomes. Operative steps, instrumentation, and postoperative cares were standardized to ensure patient consistency. We used the Charlson Comorbidity Index and the Clavien-Dindo classification system to assess comorbidities and complications respectively. We calculated the REAL score for each patient and statistically compared those who experienced an anastomotic leak to those who did not. Additionally, we conducted a univariate and multivariate analysis on other factors that may have influenced outcomes. RESULTS The study included 57 patients with a mean age of 70 years and a Charlson Comorbidity Index of 6.1 ± 1.9. The tumor was located in the upper, mid, and lower rectum in 45.6%, 33.3%, and 21.1% of cases, respectively, and 57.9% of patients had a loop ileostomy fashioned. Indocyanine green angiography was used during surgery in 53.3% of cases. We had 3 cases (5.3%) of conversion to open laparotomy. Post-operative complications according to the Clavien-Dindo system showed rates of 21.0%, 8.8%, and 7.0% for grades 1, 2, and 3b, respectively. There were 6 cases of anastomotic leakage, with 4 treated surgically and 2 conservatively. Patients with anastomotic leak had a significantly higher REAL score than those without (71.3 ± 20.5 vs. 33.7 ± 21.3). The 30-day readmission and mortality rates were 5.3% and 0%, respectively. Low preoperative serum albumin levels, preoperative blood transfusions, and the absence of indocyanine green angiography during surgery were factors significantly associated with an increased risk of anastomotic leakage according to both univariate and multivariate analyses. CONCLUSIONS The REAL score may be a helpful tool for evaluating the risk of anastomotic leak in patients undergoing laparoscopic anterior rectal resection with total mesorectal excision. Further investigation is needed to assess a potential improvement in the yield of the REAL score by incorporating the analysis of additional modifiable factors such as hypoalbuminemia, preoperative transfusion rate, and the use of indocyanine green fluorescence angiography during surgery.